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Access over workers' compensation decisions, including En Banc, Significant Panel Decisions, and writ-denied cases.

Case No. ADJ6619207 ADJ6736606
Regular
May 24, 2010

ALBERTO ALVAREZ vs. AKT DEVELOPMENT CORPORATIONS, INSURANCE OF THE WEST

The Workers' Compensation Appeals Board granted reconsideration of a decision awarding lumbar fusion surgery, finding the WCJ erred by solely relying on the *Cervantes* decision regarding timely utilization review. The Board determined that the defendant's utilization review timeliness was unclear, and the parties had agreed to an Agreed Medical Examiner (AME) to resolve the surgery dispute before *Cervantes* was issued. Furthermore, the Board held that the treating physician's recommendation for surgery must constitute substantial evidence, which was not definitively established here. Therefore, the matter was returned for further development of the record, requiring the treating physician to address the AME's concerns regarding the necessity of fusion surgery.

Workers' Compensation Appeals BoardPetition for RemovalPetition for ReconsiderationJoint Findings Award and OrderIndustrial InjuryLumbar FusionUtilization ReviewCervantes v. El Aguila Food ProductsSubstantial Medical EvidenceExpedited Hearing
References
3
Case No. 531582
Regular Panel Decision
May 13, 2021

Matter of Matteliano v. Trinity Health Corp.

Caitlyn Matteliano, a nurse assistant, suffered work-related back, knee, and leg injuries in 2015 and 2018. Her treating orthopedic surgeon, Franco Vigna, requested authorization for multi-level lumbar fusion surgery and an external bone growth stimulator due to persistent pain and degenerative disc disease, despite conservative treatments. The employer denied this request based on an independent medical examination by Anthony Leone, who deemed the surgery aggressive and inappropriate given the lack of instability. A Workers' Compensation Law Judge initially denied the request, but the Workers' Compensation Board approved it. The employer appealed, and the Appellate Division, Third Department, affirmed the Board's decision, finding substantial evidence in Vigna's testimony to support the surgery's authorization under medical treatment guidelines for degenerative disc disease where non-surgical management has failed.

Workers' CompensationLumbar Fusion SurgeryMedical Treatment GuidelinesDegenerative Disc DiseaseDiscogenic Back PainIndependent Medical ExaminationPrior AuthorizationAppellate ReviewNurse AssistantWork Injury
References
9
Case No. ADJ8436467
Regular
Sep 09, 2015

CELEINE MELENDEZ vs. KOHL'S DEPARTMENT STORE, NEW HAMPSHIRE INSURANCE COMPANY

This case concerns an employee seeking workers' compensation for back surgery, specifically an anterior lumbar discectomy and fusion. The employer contested the necessity of the surgery, arguing the administrative law judge erred in approving it. The Appeals Board affirmed the judge's decision, finding the request for authorization was valid as it reflected a change in circumstances. Therefore, the defendant is ordered to provide the authorized surgical treatment.

Workers' Compensation Appeals BoardReconsiderationUtilization ReviewAnterior Lumbar Discectomy and FusionLabor Code section 4610(g)(6)Primary Treating PhysicianIndependent Medical ReviewFindings and OrderLumbar SpineMedical Treatment Authorization
References
0
Case No. ADJ7951527
Regular
Oct 03, 2016

RONALD COYLE vs. DANE COYLE CUSTOM HOMES, INC.

The defendant sought reconsideration of an award for an applicant's industrial back injury, challenging the timeliness of the utilization review (UR) denial and the necessity of proposed spinal surgery. The Board denied reconsideration, affirming that the defendant failed to prove timely communication of the UR denial as required by law. Furthermore, substantial evidence, including reports from the treating physician and Agreed Medical Evaluator, supported the necessity of the lumbar fusion surgery. The Board found the defendant's arguments insufficient to rebut the expert medical opinions presented.

Workers' Compensation Appeals BoardPetition for ReconsiderationFindings and AwardIndustrial InjuryUtilization Review (UR) DenialTimelinessFurther Medical TreatmentSpinal SurgeryLumbar FusionRequest for Authorization (RFA)
References
2
Case No. 2023 NY Slip Op 02158 [215 AD3d 1205]
Regular Panel Decision
Apr 27, 2023

Matter of Soler v. Donato, Inc.

The claimant, Wilfredo Soler, suffered work-related back and hip injuries in August 2017. Following a denial by a Workers' Compensation Law Judge in August 2021 for lumbar fusion surgery, the Chair of the Workers' Compensation Board initially authorized the surgery in November 2021. However, this authorization was subsequently rescinded by the Chair due to the prior denial on identical medical evidence. The Workers' Compensation Board then denied Soler's application for review of the Chair's rescission, deeming it outside its scope of review. The Appellate Division, Third Department, affirmed the Board's decision, concluding that orders of the Chair are not subject to review by the Board under Workers' Compensation Law § 23.

Lumbar fusion surgeryAuthorization for treatmentRescission of orderBoard reviewAppellate DivisionScope of reviewTreating physicianEmployerInsurance carrierMedical evidence
References
3
Case No. MISSING
Regular Panel Decision
Sep 02, 2014

Matter of Pinkhasov v. Auto One Insurance

The claimant's workers' compensation claim, initially established in 2006 for various work-related injuries, was reopened in 2012 due to worsening lower back pain leading to lumbar fusion surgery in 2013. A Workers’ Compensation Law Judge (WCLJ) awarded temporary total disability benefits post-surgery, a decision upheld by the Workers’ Compensation Board panel. The employer's carrier appealed, challenging the causal relationship between the 2006 accident and the subsequent medical treatment. The Appellate Court reversed the Board's decision, finding that the medical evidence, including an independent medical examination report, did not establish a rational basis for a causal relationship, and remitted the matter for further proceedings.

Workers' CompensationTemporary Total DisabilityCausal RelationshipLumbar Fusion SurgeryMedical EvidenceIndependent Medical ExaminationReopened ClaimAppellate ReviewWorkers' Compensation LawBack Injury
References
7
Case No. SAL 0107786
Regular
Oct 16, 2007

MOLLY KIRKPATRICK vs. DOMINICAN SANTA CRUZ HOSPITAL, PSI ADMINISTERED BY OCTAGON RISK SERVICES

This case concerns an injured worker who had cervical spine surgery involving diskectomy, vertebrectomy, decompression, and fusion. The defendant sought reconsideration of an award granting temporary disability benefits beyond the statutory 104-week limit, arguing the surgery was not an amputation. The Appeals Board rescinded the prior award and returned the matter for further proceedings, as the definition of "amputation" in precedent excludes internal body parts like those removed during spinal fusion.

Workers' Compensation Appeals BoardDominican Santa Cruz HospitalOctagon Risk ServicesMolly KirkpatrickIndustrial InjuryCervical Spine SurgeryTemporary Disability IndemnityLabor Code Section 4656(c)AmputationDiskectomy
References
1
Case No. MISSING
Regular Panel Decision
Jun 02, 2008

Claim of Laezzo v. New York State Thruway Authority

The claimant suffered a work-related slip and fall in 2002, leading to injuries including his head, neck, back, and knees. His morbid obesity contributed to his back and knee issues, prompting him to seek authorization for gastric bypass surgery. The Workers’ Compensation Law Judge approved the surgery, a decision affirmed by the Workers’ Compensation Board, which found the surgery causally related to the compensable injuries. The employer and its carrier appealed, challenging the causal link. The court affirmed the Board's decision, noting substantial evidence that the claimant's weight gain was a result of the sedentary lifestyle imposed by his injuries, and that the surgery would aid in his recovery.

Workers' CompensationConsequential InjuryGastric Bypass SurgeryMorbid ObesityMedical Treatment AuthorizationCausationKnee InjuryBack InjurySedentary LifestyleBoard Decision Appeal
References
2
Case No. ADJ11053430; ADJ14397522
Regular
Jun 23, 2025

MICHAEL FISHEL vs. RICK'S LUBE AND COMPLETE AUTO, OAK RIVER INSURANCE COMPANY

Applicant Michael Fishel, an auto mechanic, sustained an injury to his back and other body parts on August 18, 2017, while employed by Rick's Lube and Complete Auto, insured by Oak River Insurance Company. The case involved extensive litigation concerning the necessity of lumbar spine surgery and the waiver of the Utilization Review/Independent Medical Review process, leading to the appointment of Dr. Laura Hatch. The Workers' Compensation Appeals Board granted the defendant's petition for reconsideration, rescinding and substituting a prior Findings and Award. The Board's decision clarified Dr. Hatch's appointment date and the scope of her evaluation, ultimately upholding the award for the applicant's lumbar spine surgery based on Dr. Hatch's medical opinions.

AOE/COEUR/IMRRegular PhysicianStipulationPetition for ReconsiderationFindings and AwardLabor Code Section 5701Lumbar Spine SurgeryQualified Medical EvaluatorPrimary Treating Physician
References
23
Case No. ADJ10034122
Regular
Dec 22, 2017

CRYSTAL WYANT vs. AMERICAN MEDICAL RESPONSE, ACE AMERICAN INSURANCE COMPANY

This case concerns an applicant's industrial back injury requiring lumbar spinal fusion. Defendants sought to overturn a prior award granting ongoing medical treatment, arguing a subsequent Utilization Review (UR) certification was invalid. The Appeals Board denied reconsideration, finding the UR process was correctly followed. A second Request for Authorization (RFA) submitted by the applicant's physician included "Change in Material Facts," triggering a new review. This second UR decision, dated September 11, 2017, authorized the surgery as medically necessary, superseding the earlier denial.

Utilization ReviewIndependent Medical ReviewReconsiderationFindings and AwardAdministrative Law JudgeLabor Code Section 4610Request for AuthorizationLumbar Spinal FusionMedical TreatmentChange in Material Facts
References
4
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